Pursuing Wellness: Recognizing Distress Impairment February 10, 2016 Allison Hallman, M.Ed....

Pursuing Wellness: Recognizing Distress & Impairment

February 10, 2016

Allison Hallman, M.Ed.Clinical CoordinatorPhysician and Professionals Health Program Ontario Medical Association

Dedicated to Doctors. Committed to Patients.

The Professionals Health Program Who We Are

•The PHP is a confidential service that provides support and

referrals to physicians, veterinarians, residents and medical

students and their family members

• You can remain anonymous and still receive services.


PHP Services:

• Information and Advice

• Intervention Services

• Assessment

• Referral for Treatment

• Case Management, Monitoring

• Advocacy

• Family Support

• Education and Prevention


New Cases By Problem Type 2007 to Current

Addictive Disorder

15%Family/Rela-

tionship19%

Legal/Licens-ing3%Mental Health

27%

Occupational22%

Psychiatric10%

Other Personal2%

Physical/Mental/Cognitive

2%Other/Unknown

1%


Objectives1. Understand how health professional students are vulnerable

2. Learn to increase self-awareness of personal functioning

3. Learn to identify and respond to distress in your colleagues


Invincible?


Stress...


Stress becomes a problem when

• There is too much

• When it lasts too long

• When it comes too often

• Perception of low choice/control


Top Ten Stressors For Medical Trainees1. Insufficient sleep

2. Fear of failure in training program

3. Death of patients

4. Fear of error in diagnosis and treatment

5. Large patient loads and long hours of work

6. Too much “scut” work

7. Social isolation

8. Inadequate sexual activity

9. Peer competition

10. High debt load


Attributes in MDs that serve us well professionally (Michael Myers)

• Control

• Perfectionism

• Competitiveness

• Dedication

• Perennial caretaker

• Emotional remoteness


Attributes in MDs that are liabilities in marriage (Ellis and Inbody, 1988)

• Control

• Perfectionism

• Competitiveness

• Dedication

• Perennial caretaker

• Emotional remoteness


Consequences of chronic stress

Physical:

• Weight gain

• Diabetes

• Cardiac disease

• Memory problems

• Headaches

• GI complaints

• Immune problems

• more…

Psychological:

• Negative thoughts

• Dysphoria

• Ruminations….worrying

• Anxieties

• Panic

• Depression

• Substance use problems

• Suicidal thoughts


Prolonged stress can lead to…

• Overwhelming capacity

• Or increase in less than helpful behaviours

• Syndromes:

- Burnout

- Compassion fatigue (decreased empathy, increased symptoms)


And More

For those who are vulnerable:

• Mood disorders

• Anxiety disorders

• Substance use disorders

• Suicide


When You Identify a Problem For

Yourself or Colleague

When you identify a problem for yourself or colleague


Difficulties Vets Faceangry ANXIOUS boundary violations depressed disillusioned discouraged

exhaustion and burnout

financial problems Isolated marital and family stress

intimate-partner-abuse mood disorders resentful

substance abuse and dependence suicide

workplace disruption


• According to a 2014 survey of American Veterinarians• 6.8% of male and 10.9% of female veterinarians who responded had

serious psychological distress, compared to 3.5% of male and 4.4% of female adult Americans

• 24.5% of male and 36.7% of female respondents experienced depressive episodes since graduating from veterinary school

• 14.4% of male and 19.1% of female respondents had suicidal thoughts• 1.1% of male and 1.4% of female respondents reported they had

attempted suicide

• We know from Physician Health that…• Significant Risk of Substance Use Disorders and Psychiatric Disorders• But shame, stigma contribute to late presentation• Increased vulnerability at times of increased stress


Risk factors

• One survey indicated 32% of first year vet students

showed symptoms of depression (compared to 23% of

human medical students)– 75% of the vet students were women (women were twice as likely to

suffer from depression)

• Factors contributing to high rates of mental illness and

suicide in vets• Heavy workload• Poor work-life balance• Familiarity with euthanasia• Access to drugs for euthanasia


Impairment:

“An impaired physician is one who is unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process, characterologic or psychiatric difficulties or excessive use of alcohol or other drugs.”


Illness vs Impairment

• Impairment term used in regulatory/legal context

• Impairment is the inability to safely practice medicine due

to the severity of an illness and its symptoms

• Can be impaired – treated and then not impaired

• Illness or being sick does not automatically mean impaired


Spectrum of Substance Use / Abuse

MisuseLow risk Use

Zero use

MildModerate

Severe

adapted fromRay Baker MD

No problem Use-relatedproblem

Substance UseDisorder (SUD)


DSM 5 Diagnostic Criteria• 11 criteria in 4 groupings (2-3=mild, 4-5=moderate, 6+=severe)

1. Impaired Control– Inability to quit or cut down, using more than intended, time spent, craving

2. Social (functional) Impairment– School, work, home obligations not met– Social and relationship problems– Social, occupational, recreational activities abandoned

3. Risky Use (using despite)– Hazardous situations– Physical or mental illness / psychological problems

4. Pharmacological (Physiological)– Tolerance and withdrawal


Heavy episodic alcohol use

Heavy episodic alcohol use • Dentists 15.9%• Nurses 8.5%• Pharmacists 12%• Physicians 7.7% (4.5% female Drs.)

Virtually all stated they did not define themselves as heavy

or problem drinker

Kenna and Wood 2005


Mental Health Disorders - Ontario

Approximately 8% of adults will experience major depression at

some time in their lives.

Postpartum depression - approximately 13%

Anxiety disorders affect 12% of the population, causing mild to

severe impairment

10 % will experience post traumatic stress

Approximately 3% of women will be affected by an eating

disorder during their lifetime


The key to recognition is knowing the performance baseline from which a person normally functions

Recognizing Impairment


“Early” Signs:• Increased expression of negative thoughts, feelings, attitudes

• Increased somatic complaints, illness and fatigue

• Withdrawal from friends and family

• Family tension, conflict, infidelity

• Less well dressed and groomed

• Declining reliability

• Emergence of unhealthy coping behaviours

• More time at work


Later Signs:• Angry outbursts at work

• Patient and staff complaints

• Professional withdrawal

• Cancelled clinics and increased absenteeism

• Deterioration of clinical skills

• Decline in school / residency performance

• Drug diversion

• Alcohol on the breath at work

• Family violence, separation and divorce


End Stage “Too Late” Signs:• Appearance of chronic illness

• Therapeutic error or mishap

• Extreme personal isolation

• Intoxication at work

• Suicidal gesturing or

• Suicide


The Tip of the Iceberg

Usually the workplace is the last place where distress and impairment shows … so even minor persistent changes in

behaviour should be taken seriously

What Can You Do?


Know Yourself


The Superhero Myth!

“I Can Do It – No Problem!”

• Sleep Deprivation

• Skipping Meals

• Insufficient Exercise

• Social Isolation

• Insufficient Leisure Pursuits

• Lack of Spiritual Development


Self-Care Checklist

How is your … Physical

Emotional

Social

Spiritual

…health?


Barriers to Self-Care

• Workload

• Time (guilt)

• Ability to delay gratification

• Circumstances: schedule, long hours

• Training to put others first

• The Physician Personality


… There Isn’t Enough Time!


Barriers to Asking for Help:

• Denial

• Confidentiality concerns

• Inability to use the health care system

• Lack of knowledge

• Absence of hope

• Insurance discrimination

• Fear, shame, stigma


“To know and not do is in fact not to know” (Guru Neem Karili Boba)

Supporting a Colleague?


SocialSocial Social

Social

ClinicalClinicalClinicalClinical

Adaptive coping Mild and reversible distress or functional

impairment

Clinical illnesses and disorders requiring

concentrated medical care

More severe, persistent injury or

impairment

Healthy Reacting Injured Ill

Peer support in the workplace

Grenier, MHI Consulting, 2012


Bystander

“A person who does not become actively involved when someone else requires help.”

Petruska Clarkson

The Bystander


Bystanding slogans:• “It’s none of my business.”• “I don’t have enough information.”• “What if I’m wrong?”• “I don’t want to get burned again.”• “There’s nothing I can do to help.”• “They did this to themselves and they have

to ask for help.”• “What if I hurt them?”• “What if they hurt me?”


Where to Seek Advice

• Legal

• Hospital or Clinic Policy

• Regulatory authorities (CVO)

• Professional Association (OVMA)

• EAP

• Professionals Health Program


Response-ability

Notice

Interpret

Assume personal responsibility

Choose a form of assistance

Act


Supporting a colleague

• Reflect your observations and concerns

• Ask how they are feeling

• Offer time to talk

• Offer time to spend together quietly

• Offer helping resources

• Facilitate use of helping resources

• Follow up


Intervention:

“Sometimes it’s not so much seeing the light as feeling the heat.”

Unknown


Intervention

•seek advice first•positive and motivational•documented evidence•planned and rehearsed•assessment pre-arranged•caring and compassionate•consequences clear


There are no wrong reasons to call!


Professionals Health Program

800-851-6606http://php.oma.org

[email protected]

Pursuing Wellness: Recognizing Distress Impairment February 10, 2016 Allison Hallman, M.Ed....

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